Anatomy of an Obamacare ‘horror story’

by Maggie Maher:

A lack of fact-checking by the media lulled into profiling the false accounts of individuals with a political agenda.

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Today’s number: 17

17% of potentially eligible Americans visited Affordable Care Act marketplaces in October, according to a survey by the Commonwealth Fund.  Of those visitors,  20% were young people between the ages of 19-29, and 20% of those who visited actually enrolled in a plan.  60% of survey respondents were aware of aware of the purpose of the health care exchanges; of those that did not enroll,  37%  cited technical problems with the exchange web sites as the reason for not enrolling.

See:  http://www.commonwealthfund.org/Publications/Data-Briefs/2013/Nov/Americans-Experiences-Marketplaces.aspx

17 million individuals will qualify for insurance subsidies, according to an analysis by the Kaiser Family Foundation. This number represents nearly 6 in 10 Americans eligible to participate in the ACA health insurance marketplaces.   To receive a subsidy through the ACA, individuals must earn between 100-400% of the federal poverty line.  Most of the individuals qualifying for subsidies reside in Texas, California, and Florida.

See: http://kff.org/health-reform/issue-brief/state-by-state-estimates-of-the-number-of-people-eligible-for-premium-tax-credits-under-the-affordable-care-act/

The way it was

There has been a lot of media attention focused on various technical difficulties related to signing up for insurance under the ACA.  There is also a lot of attention being paid to the fact that individuals who had insurance on non-grandfathered plans are now receiving termination notices — though this is hardly “news”.  (A “grandfathered” plan is one that was in existence before passage of the ACA in March 2010; a “non-grandfathered” plan is a plan that an individual or employer group purchased or set up after that time. In order to be “grandfathered”, plans had to also be upgraded to meet certain specified requirements as to coverage).

I’ve recently discovered a document that was created by an insurance company (Anthem Blue Cross) to assist its agents in understanding the standards for coverage and setting rates. This 64-page Booklet, called The California Agent Guide: Policies and Procedures Sales and Underwriting for Authorized Agentss, is quite recent, published in May, 2013. But it’s worth reading as a very detailed reminder of the hurdles that everyone had to pass in order to purchase insurance.

The list of disqualifying conditions or medications is staggering.  Kid taking medication for ADHD? that’s a 25%-75% increase in premium.  Taking prescription meds for acne? Decline.   In fact there’s a whole page listing dozens of prescription medications that would preclude a person from getting insurance.

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No, you can’t just wait until you get sick to sign up

A persistent but dangerous myth about Obamacare is that because insurers can no longer turn people down due to pre-existing conditions, that healthy people can just save their money and wait until they actually get sick or injured to sign up.  But it just doesn’t work that way.

You can’t just sign up for insurance any time — you need to do it during an open enrollment period.  This year, there is an extended period, from October 1, 2013, to March 31, 2014.  But in future years, the period will be only about 6 weeks from late October through early December.  There are some circumstances that will enable a person to sign up outside of the open enrollment period, such as change in marital status, loss of employment, or a new child in the family due to birth or adoption. But getting sick or injured is not the type of event that will allow someone to sign up outside the public open enrollment periods.

Also, insurance coverage does not start on the day you sign up. Generally, if you sign up within the first 15 days of a month, your coverage will begin on the first day of the next month. If you sign up on day 16 or later, the coverage will begin on the first day of the next succeeding month. So the people who sign up by December 15 of this year will have coverage on January 1.  A person who signs up on December 20 will have to wait until February 1 for coverage to begin.

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Who’s Helped?

Marilynn Gray-Raine:

The 64-year-old Danville artist, who survived breast cancer, has purchased health insurance for herself for decades. She watched her Anthem Blue Cross monthly premiums rise from $317 in 2005 to $1,298 in 2013. But she found out last week from the Covered California site that her payments will drop to about $795 a month.

(Reported by San Jose Mercury News, 5 October 2013)

Who’s helped:

With my medical history, I’ve never gone a day without insurance for fear of never getting it back. For those who are complaining about the cost of their coverage, be glad you’re not me. I’ve been paying over 60% of my income for health insurance since January, 2012. (That’s not a typo). I’ve met my out-of-pocket maximum several years in the last five. I’ve gotten my money’s worth, but it’s been a huge financial burden nonetheless.

(Found on a public forum on 7 October 2013)

Who’s On First?

The whole point of Obamacare was to create a safety net to guarantee medical coverage for every American.

Before enactment of the law, most Americans had coverage, either through their employers or via Medicare for seniors.  Very poor families could get coverage via Medicaid, with wider coverage for poor children under the CHIP (Children’s Health Insurance) program which expanded the scope of Medicaid for minors.

But a growing number of people were left out  or being pushed out, and the problem was getting larger every year.  People who were sporadically or irregularly employed, self-employed, part-time workers, and employees of smaller companies were not eligible for employer-provided insurance, and left to buy policies on the private market.  On the lower end of the economic spectrum, many could not afford the rates charged by insurers for even moderate coverage. Insurers were happy to sell policies to healthy people, but reluctant to sell to anyone at risk for serious illness, so they generally excluded customers with “pre-existing” conditions, and they required completion of long medical questionnaires and a medical exam before accepting most new customers. Further, as health care costs rose, so did health insurance premiums, so the boat was rocking and more and more people were falling off.

Unfortunately, many of the people who couldn’t afford insurance were the people who needed it the most: the ones who also couldn’t afford to pay out-of-pocket for routine, preventive care, and the ones who were excluded from the health insurance market precisely because they were already sick (or pregnant).  Continue reading